Incidence, risk factors and clinical impact of postoperative delirium following open reduction and internal fixation (ORIF) for hip fractures: an analysis of 7859 patients from the ACS-NSQIP hip fracture procedure targeted database

Stressors and coping strategies in older people hospitalised for hip surgery following a fall: a multiple case study

BACKGROUND

More than half of older persons admitted to an emergency department after a fall have a hip fracture and require surgery for a total hip replacement. This procedure has a high risk of postoperative complications and consequences for older persons, their informal caregivers, and the healthcare system. This study aimed to explore the perceptions of older persons, their informal caregivers and health professionals about intra-personal, inter-personal and extra-personal stressors arising from hip surgery following the fall of an older person hospitalised in orthopaedics, as well as the coping strategies used and the results obtained.

METHODS

A qualitative multiple case study. The sample consisted of eight cases. Each case consisted of one older person, their informal caregiver and the professionals involved in their care: a nurse, an orthopaedic surgeon and a physiotherapist. A total of 32 participants were recruited. Data were collected between August 2018 and February 2019 in a public hospital in French-speaking Switzerland. Intra- and inter-case analyses were performed.

RESULTS

Five topics emerged: two concerning stressors for older persons (the physical and psychological consequences of the fall and hospitalisation; the loss of relational and environmental markers and habits); two relating to the coping strategies used to face the stressors (being resilient and involved in their own care; partially meeting the older person's needs); and one regarding the results of the strategies used (reassurance through consideration of some of their needs).

CONCLUSIONS

Older persons hospitalised for hip surgery after a fall are confronted with various intra-, inter- and extra-personal stressors and have to explore, together with their informal caregivers, strategies to cope with the consequences of these stressors. Healthcare professionals should possess efficient intervention strategies to help identify and support older persons who experience various types of stressors during hospitalisation for hip surgery following a fall.

Author Response: Nocturnal Infusion of Low-dose Dexmedetomidine and Propofol for Delirium Prevention

How to cite this article: Ekkapat G, Chokengarmwong N. Author Response: Nocturnal Infusion of Low-dose Dexmedetomidine and Propofol for Delirium Prevention. Indian J Crit Care Med 2024;28(9):896.

Development of an individualized model for predicting postoperative delirium in elderly patients with hepatocellular carcinoma

Postoperative delirium (POD) is a common complication in older patients with hepatocellular carcinoma (HCC) that adversely impacts clinical outcomes. We aimed to evaluate the risk factors for POD and to construct a predictive nomogram. Data for a total of 1481 older patients (training set: n=1109; validation set: n=372) who received liver resection for HCC were retrospectively retrieved from two prospective databases. The receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA) were used to evaluate the performance. The rate of POD was 13.3% (148/1109) in the training set and 16.4% (61/372) in the validation set. Multivariate analysis of the training set revealed that factors including age, history of cerebrovascular disease, American Society of Anesthesiologists (ASA) classification, albumin level, and surgical approach had significant effects on POD. The area under the ROC curves (AUC) for the nomogram, incorporating the aforementioned predictors, was 0.798 (95% CI 0.752-0.843) and 0.808 (95% CI 0.754-0.861) for the training and validation sets, respectively. The calibration curves of both sets showed a degree of agreement between the nomogram and the actual probability. DCA demonstrated that the newly established nomogram was highly effective for clinical decision-making. We developed and validated a nomogram with high sensitivity to assist clinicians in estimating the individual risk of POD in older patients with HCC.

Comparison of patient demographics and patient-specific risk factors for readmissions following open reduction and internal fixation for acetabular fractures

PURPOSE

Acetabular fractures are highly complex injuries often resulting from high-energy trauma. The gold standard treatment for these injuries has become open reduction internal fixation (ORIF). The purpose of this study is to further this understanding and investigate how (1) patient demographics and (2) patient-specific risk factors affect 90-day readmission rates.

METHODS

A retrospective, nationwide query of private insurance database from January 1st, 2010 to October 31st, 2020 was performed using ICD-9, ICD-10, and CPT codes. Patients who underwent acetabular ORIF and were readmitted within 90 days following index procedure were included, patients who were not readmitted served as controls. Patients were divided by demographics and specific risk factors associated with readmission.

RESULTS

The query yielded a total of 3942 patients. Age and sex were found to be non-significant contributing risk factors to 90-day readmissions. Data also showed that statistically significant comorbidities included arrhythmia, cerebrovascular disease, coagulopathy, fluid and electrolyte abnormalities, and pathologic weight loss.

CONCLUSION

This study illustrated how several patient-specific risk factors may contribute to increased 90-day readmission risk following acetabular ORIF. A heightened awareness of these comorbidities in patients requiring acetabular ORIF is required to improve patient outcomes and minimize rates of readmission. Further investigation is needed to improve patient outcomes, and increase awareness of potential post-operative complications in these higher-risk patient populations.

A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial

Aims and background

The efficacy of dexmedetomidine and propofol in preventing postoperative delirium is controversial. This study aims to evaluate the efficacy of dexmedetomidine and propofol for preventing postoperative delirium in extubated elderly patients undergoing hip fracture surgery.

Materials and methods

This randomized controlled trial included participants undergoing hip fracture surgery. Participants were randomly assigned to receive dexmedetomidine, propofol, or placebo intravenously during intensive care unit (ICU) admission (8 p.m. to 6 a.m.). The drug dosages were adjusted to achieve the Richmond Agitation Sedation Scale (RASS) of 0 to -1. The primary outcome was postoperative delirium. The secondary outcomes were postoperative complications, fentanyl consumption, and length of hospital stay.

Results

108 participants were enrolled (n = 36 per group). Postoperative delirium incidences were 8.3%, 22.2%, and 5.6% in the dexmedetomidine, propofol, and placebo groups, respectively. The hazard ratios of dexmedetomidine and propofol compared with placebo were 1.49 (95% CI, 0.25, 8.95; p = 0.66) and 4.18 (95% CI, 0.88, 19.69; p = 0.07). The incidence of bradycardia was higher in the dexmedetomidine group compared with others (13.9%; p = 0.01) but not for hypotension (8.3%; p = 0.32). The median length of hospital stays (8 days, IQR: 7, 11) and fentanyl consumption (240 µg, IQR: 120, 400) were not different among groups.

Conclusion

This study did not successfully demonstrate the impact of nocturnal low-dose dexmedetomidine and propofol in preventing postoperative delirium among elderly patients undergoing hip fracture surgery. While not statistically significant, it is noteworthy that propofol exhibited a comparatively higher delirium rate.

How to cite this article

Ekkapat G, Kampitak W, Theerasuwipakorn N, Kittipongpattana J, Engsusophon P, Phannajit J, et al. A Comparison of Efficacy between Low-dose Dexmedetomidine and Propofol for Prophylaxis of Postoperative Delirium in Elderly Patients Undergoing Hip Fracture Surgery: A Randomized Controlled Trial. Indian J Crit Care Med 2024;28(5):467-474.

Effect of operative time in outcomes following surgical fixation of hip fractures: a multivariable regression analysis of 35,710 patients

BACKGROUND

Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures (n = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes.

RESULTS

Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality.

DISCUSSION

Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered.

Impact of nursing interventions on discharge disposition in patients with postoperative delirium

PURPOSE

To identify patient characteristics and perioperative factors associated with non-home patient discharges and the impact of current delirium nursing interventions on discharge disposition, especially non-home dispositions.

METHODS

A retrospective pilot chart review was conducted using electronic health records from five networked hospitals in the Mountain West region of the US. The sample comprised 75 randomly selected patients aged 65 or older who screened positive for delirium during hospitalization. Relationships between patient characteristics, nursing interventions, and discharge dispositions were analyzed using chi-square tests and logistic regression.

RESULTS

Most participants (69.3%) were discharged to non-home facilities. Delayed urinary catheter removal was a significant nursing intervention factor. Patients with delayed urinary catheter removal were at increased risk of being discharged to a non-home setting compared with those with early urinary catheter removal (aOR: 14.11, P = .010). Preoperative hypoalbuminemia and surgery durations exceeding 60 minutes were associated with non-home dispositions.

CONCLUSION

Delayed urinary catheter removal, surgery duration greater than 1 hour, and preoperative hypoalbuminemia increased the likelihood of non-home discharge placement for older adults who experience postoperative delirium.

Determining a preoperative international normalised ratio threshold safe for hip fracture surgery

INTRODUCTION

The purpose of this study was first, to assess the relationship between preoperative INR (international normalised ratio) and postoperative complication rates in patients with a hip fracture, and second, to establish a threshold for INR below which the risk of complications is comparable to those in patients with a normal INR.

METHODS

We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program and found 35,910 cases who had undergone surgery for a hip fracture between 2012 and 2018. Cases were stratified into 4 groups based on their preoperative INR levels: <1.4; ⩾1.4 and <1.6; ⩾1.6 and <1.8 and ⩾1.8. These cohorts were assessed for differences in preoperative factors, intraoperative factors, and postoperative course. Multivariate logistic regression was used to assess the risk of transfusion, 30-day mortality, cardiac complications, and wound complications adjusting for all preoperative and intraoperative factors.

RESULTS

Of the 35,910 cases, 33,484 (93.2%) had a preoperative INR < 1.4; 867 (2.4%) an INR ⩾1.4 and <1.6; 865 (2.4%) an INR ⩾ 1.6 and <1.8 and 692 (1.9%) an INR ⩾ 1.8. A preoperative INR ⩾ 1.8 was independently associated with an increased risk of bleeding requiring transfusion. A preoperative INR ⩾ 1.6 was associated with an increased risk of mortality.

CONCLUSIONS

We found that an INR of <1.6 is a safe value for patients who are to undergo surgery for a hip fracture. Below this value, patients avoid an increased risk of both transfusion and 30-day mortality seen with higher INR values. These findings may allow adjustment of preoperative protocols and improve the outcome of hip fracture surgery in this group of patients.

The Impact of Blood Transfusion in Developing Postoperative Delirium in Patients with Hip Fracture Surgery

BACKGROUND

Many studies have been conducted to explore the risk factors associated with postoperative delirium (POD) in order to understand its underlying causes and develop prevention strategies, especially for hip fracture surgery. However, the relationship between blood transfusion and POD has been heatedly debated. The purpose of this study was to evaluate the risk factors of POD and the relationship between blood transfusions and the occurrence of POD in hip fracture surgery through big data analysis.

METHODS

Medical data (including medication history, clinical and laboratory findings, and perioperative variables) were acquired from the clinical data warehouse (CDW) of the five hospitals of Hallym University Medical Center and were compared between patients without POD and with POD.

RESULTS

The occurrence of POD was 18.7% (228 of 2398 patients). The risk factors of POD included old age (OR 4.38, 95% CI 2.77-6.91; p < 0.001), American Society of Anesthesiology physical status > 2 (OR 1.84 95% CI 1.4-2.42; p < 0.001), dementia (OR 1.99, 95% CI 1.53-2.6; p < 0.001), steroid (OR 0.53 95% CI 0.34-0.82; p < 0.001), Antihistamine (OR 1.53 95% CI 1.19-1.96; p < 0.001), and postoperative erythrocyte sedimentation rate (mm/h) (OR 0.97 95% CI 0.97-0.98; p < 0.001) in multivariate logistic regression analysis. The postoperative transfusion (OR 2.53, 95% CI 1.88-3.41; p < 0.001) had a significant effect on the incidence of POD.

CONCLUSIONS

big data analytics using a CDW was a good option to identify the risk factors of POD and to prevent POD in hip fracture surgery.

Clockwise torque results in higher reoperation rates in left-sided femur fractures

PURPOSE

Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN).

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis.

RESULTS

In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (α=0.05).

CONCLUSION

This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates.

LEVEL OF EVIDENCE

Therapeutic level II.

Postoperative Delirium in Patients Receiving Hip Bipolar Hemiarthroplasty for Displaced Femoral Neck Fractures: The Risk Factors and Further Clinical Outcomes

BACKGROUND

Postoperative delirium in patients who have hip fractures may lead to poor outcomes. This study aimed to determine perioperative risk factors and clinical outcomes of postoperative delirium in patients undergoing hip bipolar hemiarthroplasty for displaced femoral neck fractures.

METHODS

Among 1,353 patients who underwent hemiarthroplasty at our institution during 2013-2021, we identified 78 patients with postoperative delirium diagnosed with the confusion assessment method. The mean delirium duration was 28 hours (range: 15-520). We also included 1:2 sex- and age-matched patients who did not have postoperative delirium after the same surgery as a matching cohort for comparison. Patient comorbidities, perioperative data, delirium occurrence, and outcomes were collected for analyses.

RESULTS

A Charlson Comorbidity Index (CCI) score ≥6 (odds ratio (OR): 2.08, P = .017), nighttime surgery (OR: 3.47, p =<.001), surgical delays (OR: 1.01, P = .012), preoperative anemia (OR: 2.1, P = .012), and blood transfusions (OR: 2.47, P = .01) may increase the risk of postoperative delirium. The presentation of delirium was associated with sepsis (OR: 3.77, P = .04), longer hospital stays (P < .001), higher 1-year mortality (OR: 3.97, P = .002), and overall mortality (OR: 2.1, P = .02).

CONCLUSION

Postoperative delirium predicted poor outcomes. Our results emphasized the importance of early identification of patients at risk and optimization of the medical conditions before and after surgery.

Frailty and comorbidity predict 30 day postoperative outcomes, independent of anatomical site of fracture

INTRODUCTION

Fragility fractures are a major threat to geriatric patients. However, it is unclear whether this patient population's inherent frailty and comorbidity or the physiologic insult caused by the fracture and its surgery contribute more to undesirable patient outcomes. Hence, this study examines if frailty and comorbidity can predict 30 day postoperative outcomes while the effects of multiple fracture sites are accounted for.

METHODS

A retrospective review of patients ≥ 65 years of age in the National Surgical Quality Improvement Program who underwent surgical treatment between 2013 and 2017 was performed. A total of 52,497 patients were included in the final analysis, including fracture cases of the extremities, limbs, and hip. Demographics, several metrics of preoperative health, temporal variables, and fracture location were tested in bivariate analysis of 30 day postoperative mortality, length of stay in hospital, discharge outcome, and complications. Significant variables were considered for multivariate logistic regression models for each outcome.

RESULTS

Frailty, comorbidity, and time to surgery were found to be the significant predictors in multivariate analysis of each 30 day postoperative outcome, independent of the effects of fracture site (p < 0.05). Examination of 30 day mortality found that American Society of Anesthesiologists Class ≥ 3 (2.30 Odds Ratio), modified Frailty Index > 0 (1.37 OR), Charleston Comorbidity Index ≥ 6 (1.63 OR), and time to surgery (1.45 OR) were especially important (all p < 0.05). Additionally, the worst outcomes were associated with fractures of the pelvis/hip and femur/knee, including 30 day mortality (5.90 and 5.12 OR, respectively; both p < 0.05).

CONCLUSION

The effects of the preoperative health were found to be independent of patient demographics and fracture site. Additionally, specific high-risk fracture sites are significant predictors of outcome, supporting the need to prioritize these patients. Clinical care pathways for geriatric patients may benefit from emphasis on these high-risk fractures and preoperative patient health.

Delirium in a surgical context from a nursing perspective: A hybrid concept analysis

Background

The term delirium has been defined in medical diagnosis criteria as a multidimensional disorder, and the term acute confusion is included in nursing classifications. Delirium can be a serious complication assessed in a patient after a surgical procedure. Still, the patient's delirium frequently remains unrecognised. Care of patients with delirium after surgical procedure is complex, and it challenges nursing expertise. From the nurses' viewpoint, delirium is associated with ambiguity of concepts and lack of knowledge. Therefore, reseach on how nurses perceive patients with delirium in a surgical context is needed.

Objective

The aim of this study was to describe the concepts of delirium and acute confusion, as well as the associated dimensions, in adult patients in a surgical context from the nursing perspective.

Design

The study used Schwartz and Barcott's hybrid concept analysis with theoretical, fieldwork, and final analytical phases.

Settings

Surgical wards, surgical intensive care units, and post-anaesthesia care units.

Data sources

A systematic literature search was performed through Pubmed (Medline), Cinahl, PsycInfo, and Embase.

Participants

Registered nurses and licensed practical nurses (n = 105) participated in the fieldwork phase.

Methods

In the theoretical phase, the concepts' working definitions were formulated based on a systematic literature search with the year limitations from 2000 until February 2021. At the fieldwork phase, the nurses' descriptions of patients with delirium were analysed using the deductive content analysis method. At the final analytical phase, findings were combined and reported.

Results

The concepts of delirium, subsyndromal delirium, and acute confusion are well defined in the literature. From the perspective of the nurses in the study, concepts were seen as a continuum not as individual diagnoses. Nurses described the continuum of delirium as a process with acute onset, duration, and recovery with the associated dimensions of symptoms, symptom severity, risk factors, and early signs. The acute phase of delirium was emphasised, and preoperative or prolonged disturbance did not seem to be relevant in the surgical care context. Patients' compliance with care may be decreased with the continuum of delirium, which might challenge both patients' recovery from surgery and the quality of nursing care.

Conclusions

In clinical practice the nurses used term confusion inaccurately. The term acute confusion might be used when illustrating an early stage of delirium. Nurses could benefit from further education where the theoretical knowledge is combined with the clinical practice. The discussion about the delirium, which covers the time both before surgery and after the acute phase should be increased.

The Assessment of Immediate Postoperative Delirium in Neurologically Intact Adult Patients Admitted to the Post-anesthesia Care Unit: A Cross-Sectional Study

Background

Immediate postoperative delirium (IPD) in the post-anesthesia care unit (PACU) can cause significant morbidity affecting everyday activities and length of stay with cost implications. This study was undertaken to find the proportion of IPD in PACU and its association with anesthesia and other perioperative factors.

Methods

After obtaining ethical approval and informed consent, this cross-sectional study was conducted in the PACU. A total of 600 consecutive adult patients (American Society of Anesthesiologists (ASA) 1-3) posted for surgery were approached between January and March 2019, of which 402 patients without neurological diseases and language and hearing discrepancies were studied. All patients had the intervention of surgery under anesthesia in a usual manner. Delirium was assessed preoperatively, postoperatively at 15 and 30 minutes, and before discharge from the PACU. IPD was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) score, while sedation/agitation was assessed using the Richmond Agitation-Sedation Scale (RASS). The primary outcomes were the proportion of IPD, association with anesthesia, and perioperative risk factors. The secondary outcomes were the length of stay, delirium treatment, and mortality.

Results

Overall, the IPD proportion was 14.7%. A significant association was demonstrated with premedication with midazolam (odds ration (OR): 3.2; 95% confidence interval (CI): 1.42-7.35; P=0.003), general anesthesia (GA) (OR: 6.3; 95% CI: 2.23-17.8; P<0.001), duration of anesthesia (126 versus 95 minutes; P=0.001), laparoscopic mode of surgical access (OR: 3.4; 95% CI: 1.8-6.4; P<0.001), and postoperative RASS >/< 0 (OR: 10.6; 95% CI: 4.69-24.11; P<0.001) at 30 minutes and before discharge from the PACU. Multivariate analysis showed the strongest association of RASS at 30 minutes with IPD.

Conclusion

The proportion of IPD was found to be 14.7% in this study, and the chances of developing IPD are high if the patient is not awake and calm in the PACU, especially if midazolam is administered as premedication, followed by general anesthesia (GA) for a long duration.

Derivation and validation of a prediction score for postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty

Introduction

Postoperative delirium is a common complication of patients undergoing hip fracture surgery or arthroplasty and is related to decreased survival time and physical function. In this study, we aim to build and validate a prediction score of postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty.

Methods

A retrospective cohort of geriatric patients undergoing hip fracture surgery or hip arthroplasty was established. Variables of included patients were collected as candidate predictors of postoperative delirium. The least absolute shrinkage and selection operator (LASSO) regression and logistic regression were used to derive a predictive score for postoperative delirium. The accuracy of the score was evaluated by the area under the curve (AUC) of the receiver operating curve (ROC). We used bootstrapping resamples for model calibration. The prediction score was validated in an extra cohort.

Results

There were 1,312 patients in the derivation cohort, and the incidence of postoperative delirium was 14.33%. Of 40 variables, 9 were identified as predictors, including preoperative delirium, cerebrovascular accident (CVA) with the modified Rankin scale, diabetes with a random glucose level, Charlson comorbidity index (CCI), age, application of benzodiazepines in surgery, surgical delay ≥2 days, creatine ≥90 μmol/L, and active smoker. The prediction score achieved a mean AUC of 0.848 in the derivation cohort. In the validation cohort, the mean AUC was 0.833. The prediction model was well-calibrated in the two cohorts.

Conclusion

Based on retrospective data, a prediction score for postoperative delirium in geriatric patients undergoing hip fracture surgery or hip arthroplasty was derived and validated. The performance of the scoring system outperformed the models from previous studies. Although the generalization ability of the score needs to be tested in similar populations, the scoring system will enable delirium risk stratification for hip fracture patients and facilitate the development of strategies for delirium prevention.

One-year mortality after hip fracture surgery: urban-rural differences in the Colombian Andes

To determine urban-rural differences influencing mortality in patients with hip fracture in Colombian Andes Mountains over a 1-year period.

PURPOSE

To identify the urban-rural differences of sociodemographic variables, fracture-related characteristics, and preoperative and postoperative clinical factors associated with 1-year mortality in patients over 60 years old who underwent hip fracture surgery in the Andes Mountains.

METHODS

A total of 126 patients with a fragility hip fracture during 2019-2020 were admitted to a tertiary care hospital. They were evaluated preoperatively and followed up until discharge. Those who survived were contacted by telephone at 1, 3, and 12 months. Univariate, bivariate, and Kaplan-Meier analyses with survival curves were performed. Relative risk was calculated with a 95% confidence interval.

RESULTS

A total of 32.5% of the patients died within 1 year after surgery, with a significant difference between those who resided in rural areas (43.1%) and those who resided in urban areas (23.5%) (RR 1.70; 95% CI, 1.03 to 2.80, p = 0.036). In the multivariate analysis, anemia (hemoglobin level ≤ 9.0 g/dL during hospitalization) (RR 6.61; 95% CI, 1.49-29.37, p = 0.003), a blood transfusion requirement (RR 1.47; 95% CI, 1.07 to 2.01, p = 0.015), the type of fracture (subtrochanteric fracture (RR = 4.9, 95% CI = 1.418-16.943, p = 0.005)), and postoperative acute decompensation of chronic disease (RR 1.60; 95% CI, 1.01 to 2.53, p = 0.043) were found to be independent predictive factors of 1-year mortality after surgery.

CONCLUSIONS

There was a difference in 1-year mortality between patients from rural and urban areas. More studies must be conducted to determine whether rurality behaves as an independent risk factor or is related to other variables, such as the burden of comorbidities and in-hospital complications.

The effect of postoperative weight-bearing status on mortality rate following proximal femoral fractures surgery

INTRODUCTION

Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications.

METHODS

We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P < 0.05 was the significant threshold.

RESULTS

There were 186 patients in the non-weight-bearing group, 127 patients in the partial-weight-bearing group and 1791 patients in the full weight-bearing group. We found a significant difference in the type of diagnosis between cohorts (P < 0.001 in univariate, P < 0.001 in multivariate), but not in fixation type (P < 0.001 in univariate, but P = 0.76 in multivariate). The full weight-bearing group was diagnosed most with pertrochanteric fracture, 48.0%, and used Richard's nailing predominantly. Finally, we found that age was not a significant determinant of mortality rate but only weight-bearing cohort (P = 0.13 vs. P < 0.001, respectively).

CONCLUSION

We recommend early weight-bearing, which may act to decrease the mortality rate compared to non-weight-bearing and partial weight-bearing. In addition, appropriate expectations and standardizations should be set since age and type of diagnosis act as significant predictors of weight-bearing status.

Delirium risk in geriatric hip hemi-arthroplasty (DRIGHA): Development and validation of a novel score using a national data

BACKGROUND

In-hospital delirium after hip hemi-arthroplasty results in a prolonged hospital course and an increase in morbidity and mortality. Early identification of high-risk patients and preventive strategies can reduce the occurrence of delirium. The purpose of the study is to identify the risk factors of delirium and create a scoring system for point of care physicians. The risk factors were created and validated in the study.

HYPOTHESIS

Certain factors are associated with in-hospital delirium after hip hemi-arthroplasty in geriatric patients.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2019 was accessed for the study. The study included all geriatric patients, ages 65 years and older, who underwent hip hemi-arthroplasty following a hip fracture. A multivariable analysis was performed to identify the risk of delirium using all the available information including patient demography, timing of surgery, comorbidities, and infective complications. Eighty percent of the data were used to develop a risk model, and 20% of the data were used to validate the model. A Receiving Operating Characteristics (ROC) curve was created. The Area Under the Curve (AUC) was calculated with a 95% confidence interval (CI). A Delirium Risk in Geriatric Hip Hemi-Arthroplasty (DRIGHA) score was created.

RESULTS

Out of 13,174 patients who qualified for the study, 3924 (29.8%) patients developed in-hospital delirium. The risk model showed advanced age, male gender, prior history of delirium and dementia, certain comorbidities, and complications were associated with a higher incidence of in-hospital delirium. The AUC was 0.79 (95% CI, 0.78-0.80). The DRIGHA score predicted the risk of delirium from 8 to 99.4%.

CONCLUSION

Certain demography characteristics, comorbidities and infective complications were associated with a higher risk of developing in-hospital delirium. A DRIGHA score can be calculated at the bedside through a web-based calculator. Preventive strategies in high-risk patients will reduce the incidence of delirium.

The Relationship between Perioperative Blood Transfusion and Postoperative Delirium in Patients Undergoing Spinal Fusion Surgery: Clinical Data Warehouse Analysis

Background and Objectives: For preventing postoperative delirium (POD), identifying the risk factors is important. However, the relationship between blood transfusion and POD is still controversial. The aim of this study was to identify the risk factors of POD, to evaluate the impact of blood transfusion in developing POD among people undergoing spinal fusion surgery, and to show the effectiveness of big data analytics using a clinical data warehouse (CDW). Materials and Methods: The medical data of patients who underwent spinal fusion surgery were obtained from the CDW of the five hospitals of Hallym University Medical Center. Clinical features, laboratory findings, perioperative variables, and medication history were compared between patients without POD and with POD. Results: 234 of 3967 patients (5.9%) developed POD. In multivariate logistic regression analysis, the risk factors of POD were as follows: Parkinson’s disease (OR 5.54, 95% CI 2.15–14.27; p < 0.001), intensive care unit (OR 3.45 95% CI 2.42–4.91; p < 0.001), anti-psychotics drug (OR 3.35 95% CI 1.91–5.89; p < 0.001), old age (≥70 years) (OR 3.08, 95% CI 2.14–4.43; p < 0.001), depression (OR 2.8 95% CI 1.27–6.2; p < 0.001). The intraoperative transfusion (OR 1.1, 95% CI 0.91–1.34; p = 0.582), and the postoperative transfusion (OR 0.91, 95% CI 0.74–1.12; p = 0.379) had no statistically significant effect on the incidence of POD. Conclusions: There was no relationship between perioperative blood transfusion and the incidence of POD in spinal fusion surgery. Big data analytics using a CDW could be helpful for the comprehensive understanding of the risk factors of POD, and for preventing POD in spinal fusion surgery.

Bipolar hemiarthroplasty may reduce cerebrovascular accidents and improve early weight-bearing in the elderly after femoral neck fracture

Cerebrovascular accidents (CVA) in the elderly population after femoral neck fracture remain great concern for physicians. Specifically, surgical fixation techniques, such as bipolar hemiarthroplasty (HA) and internal fixation play a significant role in influencing the occurrence of postoperative CVA in the elderly population.In order to identify 2 cohorts, we used a rigid selection process based on our institution's database. The cohorts were comprised of a HA cohort and a cannulated screw cohort, of which underwent femoral neck surgery, performed by 3 fellowship trained surgeons from 2003 to 2014. Risk factors were documented and measured, including Coumadin use and hypertension, and postoperative complications such as CVA and death rate were also recorded. A P-value of <.05 was determined to be statistically significant.A power analysis was performed and achieved a power of 0.95. We found a non-significant reduction in CVA for bipolar HA (3.6% CVA vs 0.0% in the non-CVA group, P = .48) and a non-significant increase in CVA for cannulated screw use (7.6% CVA vs 14.4% in the non-CVA group, P = .11). In addition, we found a significant difference in terms of weight-bearing status at 6-weeks postoperatively (0.95 vs 2.0, P < .0001), favoring the bipolar HA group.Among the advantages of bipolar HA surgery, surgeons should consider its value in reducing the occurrence of postoperative CVA. Furthermore, patients who underwent bipolar HA had improved weight-bearing status postoperatively compared with cannulated screw fixation.

Prediction of Postoperative Delirium in Geriatric Hip Fracture Patients: A Clinical Prediction Model Using Machine Learning Algorithms

Introduction

Postoperative delirium in geriatric hip fracture patients adversely affects clinical and functional outcomes and increases costs. A preoperative prediction tool to identify high-risk patients may facilitate optimal use of preventive interventions. The purpose of this study was to develop a clinical prediction model using machine learning algorithms for preoperative prediction of postoperative delirium in geriatric hip fracture patients.

Materials & Methods

Geriatric patients undergoing operative hip fracture fixation were queried in the American College of Surgeons National Surgical Quality Improvement Program database (ACS NSQIP) from 2016 through 2019. A total of 28 207 patients were included, of which 8030 (28.5%) developed a postoperative delirium. First, the dataset was randomly split 80:20 into a training and testing subset. Then, a random forest (RF) algorithm was used to identify the variables predictive for a postoperative delirium. The machine learning-model was developed on the training set and the performance was assessed in the testing set. Performance was assessed by discrimination (c-statistic), calibration (slope and intercept), overall performance (Brier-score), and decision curve analysis.

Results

The included variables identified using RF algorithms were (1) age, (2) ASA class, (3) functional status, (4) preoperative dementia, (5) preoperative delirium, and (6) preoperative need for mobility-aid. The clinical prediction model reached good discrimination (c-statistic = .79), almost perfect calibration (intercept = −.01, slope = 1.02), and excellent overall model performance (Brier score = .15). The clinical prediction model was deployed as an open-access web-application: https://sorg-apps.shinyapps.io/hipfxdelirium/.

Discussion & Conclusions

We developed a clinical prediction model that shows promise in estimating the risk of postoperative delirium in geriatric hip fracture patients. The clinical prediction model can play a beneficial role in decision-making for preventative measures for patients at risk of developing a delirium. If found to be externally valid, clinicians might use the available web-based application to help incorporate the model into clinical practice to aid decision-making and optimize preoperative prevention efforts.

Red Blood Cell Transfusion and Postoperative Delirium in Hip Fracture Surgery Patients: A Retrospective Observational Cohort Study

Background

Patients having hip fracture surgery are at high risk for postoperative delirium. Red blood cell (RBC) transfusion may increase postoperative delirium risk by causing neuroinflammation. We hypothesized that RBC transfusion would be associated with postoperative delirium in patients having hip fracture surgery.

Methods

An observational cohort study was performed using the United States National Surgical Quality Improvement Program (NSQIP) participant use files for hip fracture from 2016 to 2018. Propensity score analysis and inverse probability of treatment weighting (IPTW) were used to reduce bias from confounding. An IPTW adjusted odds ratio for developing postoperative delirium was calculated for patients who received RBC transfusion during surgery or in the 72 hours after.

Results

There were 20,838 patients who had eligible current procedural terminology (CPT) codes for primary hip fracture surgery and complete study data. After employing strict exclusions to balance covariates and reduce bias, 3,715 patients remained in the IPTW cohort. Of these, 626 patients (16.9%) received RBC transfusion and 665 patients (17.9%) developed postoperative delirium. IPTW adjustment led to good covariate balance between patients who received RBC transfusion and those who did not. Patients who received RBC transfusion had significantly higher odds of postoperative delirium, IPTW adjusted odds ratio = 1.21, 95% CI = 1.03 to 1.43, and P = 0.02. Discharge location also differed significantly between patients who received RBC transfusion and those who did not (P < 0.001) with in-hospital mortality or referral to hospice occurring in 1.6% of patients who received RBC transfusion and 1.3% of patients who were not transfused.

Conclusion

RBC transfusion is associated with increased odds of postoperative delirium after hip fracture surgery and may be associated with worse clinical outcome.

Comparison of surgical invasiveness and morbidity of adult spinal deformity surgery to other major operations

BACKGROUND CONTEXT

Adult spinal deformity (ASD) surgeries are complex, involving long operative times and surgical morbidity. It is currently unclear how the invasiveness of ASD surgery compares to other major operations.

PURPOSE

To: (1) develop a quantitative score of surgical morbidity and invasiveness, and (2) compare this score between ASD surgery and other major operations.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

A prospective surgical registry was used to identify all patients undergoing ASD surgery involving ≥ 7 segments. Seventeen additional procedures were included: coronary artery bypass grafting (CABG), pancreatectomy, and esophagectomy, among others.

OUTCOME MEASURES

Perioperative factors (operative time, transfusions, ventilation) and complications were collected and combined with a previously validated Postoperative Morbidity Survey to create a Surgical Invasiveness and Morbidity Score (SIMS).

METHODS

Computed scores were compared across surgeries using Welch's t-test. Multiple linear regression modeling was used to compare the SIMS of major surgeries relative to ASD while controlling for patient demographics and comorbidities.

RESULTS

A total of 1,245,282 surgical patients were included, 4,656 of which underwent ASD surgery. After multiple regression modeling controlling for patient demographics and comorbidities, ASD surgery ranked fourth in SIMS. ASD surgery had a significantly greater SIMS than 13 other major procedures including 6th esophagectomy (adjusted mean difference=-0.05, 95%CI -0.01-0.09, p<.001), 8th pancreatectomy (-0.40, 0.37-0.44, p<.001), 11th craniotomy for tumor (-1.01, 0.98-1.04, p<.001), and 12th sacral chordoma resection (-1.31, 1.26-1.37, p<.001).

CONCLUSIONS

ASD surgery was associated with significantly greater SIMS than many other major operations, even when controlling for important perioperative factors. These data have implications for patient counseling, resource allocation, and informed consent.

Impact of dexmedetomidine supplemented analgesia on delirium in patients recovering from orthopedic surgery: A randomized controlled trial

Background

Dexmedetomidine promotes normal sleep architecture; the drug also improves analgesia. We therefore tested the hypothesis that supplementing intravenous analgesia with dexmedetomidine reduces delirium in older patients recovering from orthopedic surgery.

Methods

In this double-blinded randomized controlled trial, we enrolled 712 older (aged 65–90 years) patients scheduled for major orthopedic surgery. Postoperative analgesia was provided by patient-controlled intravenous sufentanil, supplemented by randomly assigned dexmedetomidine (1.25 μg/mL) or placebo, for up to three days. The primary outcome was the incidence of delirium assessed twice daily with the Confusion Assessment Method. Among secondary outcomes, pain severity was assessed twice daily and sleep quality once daily, each with an 11-point scale where 0 = no pain/the best possible sleep and 10 = the worst pain/the worst possible sleep.

Results

The incidence of postoperative delirium was 7.3% (26 of 354) with placebo and 4.8% (17 of 356) with dexmedetomidine; relative risk 0.65, 95% CI 0.36 to 1.18; P = 0.151. Dexmedetomidine reduced pain both at rest (median difference -1 to 0 points, P ≤ 0.001) and with movement (-1 points, P < 0.001) throughout the first 5 postoperative days; it also improved subjective sleep quality during the first 3 postoperative days: day one median difference -1 point (95% CI -1 to 0), P = 0.007; day two 0 point (-1 to 0), P = 0.010; and day three 0 point (-1 to 0), P = 0.003. The incidence of adverse events was similar in each group.

Conclusions

Supplementing sufentanil intravenous analgesia with low-dose dexmedetomidine did not significantly reduce delirium, but improved analgesia and sleep quality without provoking adverse events.

Trial registration

www.chictr.org.cn: ChiCTR1800017182 (Date of registration: July 17, 2018); ClinicalTrials.gov:NCT03629262 (Date of registration: August 14, 2018).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01441-3.

Immediate weight-bearing is safe following lateral locked plate fixation of periprosthetic distal femoral fractures

PURPOSE

This study aimed to determine whether unrestricted weight-bearing as tolerated (WBAT) following lateral locking plate (LLP) fixation of periprosthetic distal femoral fractures (PDFFs) is associated with increased failure and reoperation, compared with restricted weight-bearing (RWB).

MATERIALS AND METHODS

In a retrospective cohort study of consecutive patients with unilateral PDFFs undergoing LLP fixation, patients prescribed WBAT were compared with those prescribed 6 weeks of RWB. The primary outcome measure was reoperation. Kaplan-Meier and Cox multivariable analyses were performed.

RESULTS

There were 43 patients (mean age 80.9 ± 11.7 years, body mass index 26.8 ± 5.7 kg/m² and 86.0% female): 28 WBAT and 15 RWB. There were more interprosthetic fractures in the RWB group (p = 0.040). Mean follow-up was 3.8 years (range 1.0-10.4). Eight patients (18.6%) underwent reoperation. Kaplan-Meier analysis demonstrated no difference in 2-year survival between WBAT (80.6%, 95% CI 65.3-95.9) and RWB (83.3%, 95% CI 62.1-100.0; p = 0.54). Cox analysis showed increased reoperation risk with medial comminution (hazard ratio 10.7, 95% CI 1.5-80; p = 0.020) and decreased risk with anatomic reduction (hazard ratio 0.11, 95% CI 0.01-1.0; p = 0.046). Immediate weight-bearing did not significantly affect the risk of reoperation compared with RWB (relative risk 1.03, 95% CI 0.61-1.74; p = 0.91).

CONCLUSIONS

LLP fixation failure was associated with medial comminution and non-anatomic reductions, not with postoperative weight-bearing. Medial comminution should be managed with additional fixation. Weight-bearing restrictions additional to this appear unnecessary and should be avoided.

Postoperative delirium - treatment and prevention

PURPOSE OF REVIEW

Postoperative delirium (POD) is one of the most severe complications after surgery.The consequences are dramatic: longer hospitalization, a doubling of mortality and almost all cases develop permanent, yet subtle, cognitive deficits specific to everyday life. Actually, no global guideline with standardized concepts of management exists. Advances in prevention, diagnosis and treatment can improve recognition and risk stratification of delirium and its consequences.

RECENT FINDINGS

Management of POD is a multiprofessional approach and consists of different parts: First, the detection of high-risk patients with a validated tool, preventive nonpharmacological concepts and an intraoperative anesthetic management plan that is individualized to the older patient (e.g. avoiding large swings in blood pressure, vigilance in maintaining normothermia, ensuring adequate analgesia and monitoring of anesthetic depth). In addition to preventive standards, treatment and diagnostic concepts must also be available, both pharmaceutical and nonpharmacological.

SUMMARY

Not every POD can be prevented. It is important to detect patients with high risk for POD and have standardized concepts of management. The most important predisposing risk factors are a higher age, preexisting cognitive deficits, multimorbidity and an associated prodelirious polypharmacy. In view of demographic change, the implementation of multidisciplinary approaches to pharmacological and nonpharmacological POD management is highly recommended.

Disparities in Physical and Psychological Symptoms in Hospitalized African American and White Persons with Dementia

Objectives: This study examined differences in physical function, delirium, depressive symptoms, and behavioral and psychological symptoms of dementia (BPSD) in hospitalized African American and white older adults with dementia. Methods: This secondary data analysis using baseline data from an ongoing trial testing family-centered function-focused care included African American (n = 159) and white persons (n =135) with dementia. Results: A multivariate analysis of covariance showed that controlling for relevant demographic and health characteristics, African Americans with dementia had lower physical function, more delirium, and more depressive symptoms upon admission than white participants. There were no significant differences in BPSD between African American and white persons. Discussion: To our knowledge, this is the first study to examine racial differences in admission symptoms of hospitalized persons with dementia. While the findings are preliminary, they can be used to inform the design of future research, including identifying the causes of disparities.

The Relative Impact of Specific Postoperative Complications on Older Patients Undergoing Hip Fracture Repair

BACKGROUND

Hip fractures affect a vulnerable population and are associated with high rates of morbidity, mortality, and resource utilization. Although postoperative complications are a known driver of mortality and resource utilization, the comparative impacts of specific complications on outcomes is unknown. This study assessed which complications are associated with the highest effects on mortality and resource utilization for older patients who undergo hip fracture repair.

METHODS

Patients ≥ 65 years of age who underwent hip fracture repair during 2016-2017 included in the Hip Fracture Targeted ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database populated the data set. Prolonged hospitalization (≥ 75th percentile) and 30-day mortality and readmission were the primary outcomes. Population attributable fractions (PAFs) were used to quantify the anticipated reduction in the primary outcomes that would result from complete prevention of 10 postoperative complications.

RESULTS

Of 17,755 patients across 117 hospitals, 70.9% were female, 26.0% were over age 90, 22.8% had an American Society of Anesthesiologists (ASA) score of 4-5, and 53.9% presented with an intertrochanteric fracture. Postoperative delirium affected 29.8% of patients and was associated with death (PAF 18.0%; 95% confidence interval [CI] = 13.2-22.5), prolonged hospitalization (PAF 14.3%; 95% CI = 12.7-15.8), and readmission (PAF 15.0%; 95% CI = 11.3-18.6). Pneumonia affected 4.1% of patients and was associated with death (PAF 10.9%; 95% CI = 8.9-12.8), prolonged hospitalization (PAF 4.0%; 95% CI = 3.5-4.5), and readmission (PAF 9.1%; 95% CI = 7.5-10.7). The impact of the other eight complications was comparatively small.

CONCLUSION

Postoperative delirium and pneumonia are the highest-impact complications for older hip fracture repair patients. These complications should be prioritized in quality improvement efforts that target this patient population.

Intrathecal Morphine Is Associated with Less Delirium Following Hip Fracture Surgery: A Register Study

Background

Delirium is a common complication after proximal femoral fracture surgery, with pain and opioid consumption as the contributing factors. The administration of intrathecal morphine may decrease these factors postoperatively and potentially reduce delirium.

Objectives

This research aimed to study the association between the use of intrathecal morphine and the occurrence of delirium.

Methods

A retrospective analysis of a prospective register kept in a non-academic hospital in the Netherlands was performed. The register contained data of all patients with proximal femur fractures that were surgically treated with osteosynthesis or prosthesis. Patients receiving spinal anesthesia (SA group) were compared with patients receiving spinal anesthesia with the addition of intrathecal morphine (SIM group). The administration of either SA or SIM was based on the preference of the anesthesiologist. The primary outcome was the incidence of delirium, as defined by the DSM-V classification. The follow-up lasted until hospital discharge. Both univariate and multivariate analyses were performed.

Results

The SA group consisted of 451 patients, and the SIM group included 34 patients. Delirium occurred in 19.7% in the SA group versus 5.9% in the SIM group (P = 0.046). This association remained significant after correction in multivariate analysis (OR of delirium in the SA group, 95% CI: 1.062 - 21.006, P = 0.041). Additionally, multivariate analysis revealed that age, gender, preoperative cognitive impairment, and fracture treatment (osteosynthesis or prosthesis) were independently associated with delirium.

Conclusions

This retrospective study found an independent association between the use of intrathecal morphine and a lower incidence of delirium. This clinically relevant decrease in delirium should be studied in a prospective randomized study.

Risk factors for postoperative delirium in elderly patients after spinal fusion surgery

Background

Postoperative delirium (POD) has an incidence rate of 9% to 41%. It is directly linked to decreasing cognitive function, increasing length of hospitalization and cost, as well as other complications and mortality. We aimed to assess the risk factors for POD among elderly patients by analyzing data from those who underwent spinal surgery.

Methods

This study included 446 patients aged 65 years or older who underwent spinal surgery at our institution between March 2013 and May 2018. Data were collected retrospectively from the patients' electronic medical records, and logistic regression was used to identify the risk factors associated with POD. The diagnosis of POD was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and was made through consultation with a psychiatrist during postoperative hospitalization and before discharge.

Results

Seventy-eight (78/446, 17.4%) patients were diagnosed with POD. The most relevant risk factor for POD was preoperative cognitive dysfunction (odds ratio [OR], 4.37; 95% confidence interval [CI], 1.60 to 11.93; P = 0.004), followed by emergency surgery (OR, 2.70; 95% CI, 1.27 to 5.74; P = 0.01), age (OR, 1.19; 95% CI, 1.13 to 1.26; P < 0.001), and anesthesia time (OR, 1.01; 95% CI 1.00 to 1.01; P = 0.002).

Conclusions

Preoperative cognitive dysfunction, emergency surgery, age, and anesthesia time were factors that affected POD occurrence after spinal surgery. Patients with such associated factors may be at a higher risk for POD when undergoing spinal surgery, and hence, careful management may be necessary for these patients.

Preoperative prognostic nutritional index predicts postoperative delirium in elderly patients after hip fracture surgery

BACKGROUND

Postoperative delirium (POD) is a very common complication in elderly patients after hip fracture surgery, which has poorly understood pathophysiology. This study aimed to investigate potential risk factors for POD.

METHODS

Elderly patients (aged ≥65 years) scheduled to undergo selective surgery in our hospital were consecutively recruited. Patient characteristics, preoperative laboratory tests and prognostic nutritional index (PNI) levels were compared between patients with or without POD. The risk factors for POD were evaluated by univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of PNI and age for POD.

RESULTS

Fifty-seven of the 163 enrolled patient had suffered POD within postoperative day 7 with an incidence of 35.0%. Multivariate logistic analyses revealed that an advanced age (cut-off value: 71.5 years, sensitivity: 48.1%, specificity: 75.4%, odds ratio (OR): 3.24, 95% CI: 1.16-8.69, P = 0.026) and lower PNI level (cut-off value: 47.45, sensitivity: 86.0%, specificity: 51.9%, OR: 2.88, 95% CI: 1.25-6.64, P = 0.012) were two independent predictive factors associated with POD. According to the ROC curve analysis, preoperative PNI level was a predictor for POD with an area under the curve of 0.686 (95% CI: 0.604-0.767, P < 0.001).

CONCLUSIONS

Advanced age and lower preoperative PNI level were significantly associated with POD in elderly patients after hip fracture surgery.

Preoperative Evaluation of the Frail Patient

Perioperative management of older adults is a complex field that is heavily influenced by the clinical heterogeneity of older adults. Frailty-a geriatric syndrome in which a patient is more vulnerable to stressors due to decreases in physical function and reserve-has been indicative of adverse postoperative outcomes. Many tools have been developed to measure frailty that incorporate a variety of factors including physical and cognitive function, comorbidities, self-reported measures of health, and clinical judgment. Most of these frailty assessment tools are able to identify a subset of patients at risk of adverse outcomes including postoperative complications, longer hospital length of stay, discharge to a higher level of care, and mortality. Frailty assessment before surgical interventions can also guide discussions among patients, their families, anesthesiologists, and surgeons to tailor operative plans for patients to mitigate this increased risk. Studies are ongoing to identify interventions in frail patients that can improve postoperative outcomes, but high-quality data in the form of randomized controlled trials are lacking at this time.

Development of a Risk Score to Predict Postoperative Delirium in Patients With Hip Fracture

BACKGROUND

Post-hip fracture surgery delirium (PHFD) is a significant clinical problem in older patients, but an adequate, simple risk prediction model for use in the preoperative period has not been developed.

METHODS

The 2016 American College of Surgeons National Surgical Quality Improvement Program Hip Fracture Procedure Targeted Participant Use Data File was used to obtain a cohort of patients ≥60 years of age who underwent hip fracture surgery (n = 8871; randomly assigned to derivation [70%] or validation [30%] cohorts). A parsimonious prediction model for PHFD was developed in the derivation cohort using stepwise multivariable logistic regression with further removal of variables by evaluating changes in the area under the receiver operator characteristic curve (AUC). A risk score was developed from the final multivariable model.

RESULTS

Of 6210 patients in the derivation cohort, PHFD occurred in 1816 (29.2%). Of 32 candidate variables, 9 were included in the final model: (1) preoperative delirium (adjusted odds ratio [aOR], 8.32 [95% confidence interval {CI}, 6.78-10.21], 8 risk score points); (2) preoperative dementia (aOR, 2.38 [95% CI, 2.05-2.76], 3 points); (3) age (reference, 60-69 years of age) (age 70-79: aOR, 1.60 [95% CI, 1.20-2.12], 2 points; age 80-89: aOR, 2.09 [95% CI, 1.59-2.74], 2 points; and age ≥90: aOR, 2.43 [95% CI, 1.82-3.23], 3 points); (4) medical comanagement (aOR, 1.43 [95% CI, 1.13-1.81], 1 point); (5) American Society of Anesthesiologists (ASA) physical status III-V (aOR, 1.40 [95% CI, 1.14-1.73], 1 point); (6) functional dependence (aOR, 1.37 [95% CI, 1.17-1.61], 1 point); (7) smoking (aOR, 1.36 [95% CI, 1.07-1.72], 1 point); (8) systemic inflammatory response syndrome/sepsis/septic shock (aOR, 1.34 [95% CI, 1.09-1.65], 1 point); and (9) preoperative use of mobility aid (aOR, 1.32 [95% CI, 1.14-1.52], 1 point), resulting in a risk score ranging from 0 to 20 points. The AUCs of the logistic regression and risk score models were 0.77 (95% CI, 0.76-0.78) and 0.77 (95% CI, 0.76-0.78), respectively, with similar results in the validation cohort.

CONCLUSIONS

A risk score based on 9 preoperative risk factors can predict PHFD in older adult patients with fairly good accuracy.

The pharmacotherapeutic management of postoperative delirium: an expert update

INTRODUCTION

Postoperative delirium is a common sequela in older adults in the peri-operative period leading to poor outcomes with a complex pathophysiology which has led to a variety of different pharmacologic agents employed in attempts to prevent and treat this syndrome. No pharmacologic agent has been approved to treat this disorder, but this review discusses the pharmacologic strategies which have been tried based on the hypotheses of the causation of the syndrome including neurotransmitter imbalance, inflammation, and oxidative stress.

AREAS COVERED

Systematic reviews and meta-analyses of randomized clinical trials (RCTs) were included via search of electronic databases specifically for the terms postoperative delirium and pharmacologic treatments. With this approach, the recurrent topics of analgesia and sedation, antipsychotics, acetylcholinesterase inhibitors (AchE-Is), inflammation, and melatonin were emphasized and provided the outline for this review.

EXPERT OPINION

Research evidence does not support any particular agent in any of the pharmacologic classes reviewed. However, there is some potential benefit with dexmedetomidine, melatonin, and the monitoring of anesthetic agents all of which need further clinical trials to validate these conclusions. Exploration of ways to improve studies and the application of novel pharmacologic agents may offer future benefit.

Postoperative Delirium is Associated with Negative Outcomes and Long-Term Mortality in Elderly Koreans: A Retrospective Observational Study

Background and objectives: Delirium is an acute state that causes confusion and occurs frequently after surgery in elderly patients. Delirium is also related to various clinical complications. With increasing numbers of surgeries performed on elderly Koreans, the number of cases of delirium and associated complications will likely rise. The purpose of the present study was to determine whether postoperative delirium in elderly Korean patients negatively influenced other clinical outcomes and their long-term mortality. Materials and Methods: The medical records of 1016 elderly patients (65 years or older) who underwent major abdominal surgery from January 2014 to December 2016 were retrospectively investigated. To determine long-term mortality, patients were followed for up to 12 months post-operation. Results: Delirium occurred in 194 patients (18.3%). Postoperative delirium was significantly associated with the length of hospital stay (B = 2.72), length of ICU stay (B = 18.78), adverse medical events (OR = 2.26, CI = 1.45–3.52), reoperation (OR = 5.50, CI = 1.66–18.22), ICU readmission (OR = 14.10, CI = 2.97–66.90), medical costs (B = 2473.85), discharge to somewhere other than the patient’s home (OR = 6.01, CI = 3.35–10.76), hospital readmission (OR = 2.73, CI = 1.45–5.14), in-hospital mortality (OR = 3.34, CI = 1.21–9.19), three-month mortality (HR = 3.22, CI = 1.27–8.14), six-month mortality (HR = 2.85, CI = 1.28–6.36), and 12-month mortality (HR = 2.19, CI = 1.10–4.32). Conclusions: Postoperative delirium in elderly Korean patients was associated with negative clinical outcomes and mortality. For rapid recovery and increased survival rates in surgical patients, effective delirium-prevention care and active delirium treatments are necessary.

Functional capacity as a predictor of postoperative delirium in transurethral resection of prostate patients in Northeast Brazil

INTRODUCTION

Postoperative delirium (POD) is a common disorder and its frequency varies from 15% to 25% after major elective surgery. There are few data on the incidence of POD in Brazil. Here, we sought to assess the incidence of POD following transurethral resection of the prostate (TURP) and to examine precipitating and predisposing factors associated.

METHOD

We performed a prospective observational study of elderly male patients undergoing TURP (N=55) in Northeast Brazil. Information on demographic, medical, cognitive and functional characteristics were collected. The participants were followed until hospital discharge. POD was diagnosed by the Confusion Assessment Method.

RESULTS

A total of three participants (5.45%) were identified with POD. Episodes of delirium lasted 3±1 days. The study sample consisted of a healthy population. Patients with POD had longer hospital stay and more precipitating factors. The POD group showed statistically significant lower Barthel index score (p<0.001) and higher Pfeffer's Functional Activities Questionnaire scores (p<0.01).

CONCLUSION

Loss of functional capacity was associated with POD in a healthy population of elderly patients undergoing TURP.